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WELL/PUMP PERMIT v SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 951 2 - 1T.900 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Sd� X51 s m JOB ADDRESS � r Je CITY/ZIP n' Ci�I�'T�/� APN /I/I/ D7,"�� m CROSS STREET PARCEL SIZE LAND USE APPLICATION# A cn OWNER NAME ��yG PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR u fir✓ p PHO E U l y�2 11 CONTRACTOR ADDRESS l r r— C CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 r] C-61 ❑ D-09 11 Other NUMBER •J•)qQ`f V ZIEXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name L;ontact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump )(Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel LiPlastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP XSubmersiblell Turbine ❑ Other HP Pump Set ft Standing Water Level 1 ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMP ION LAWS. MINIMUM 2 UFR ADVANCE NOTICE R MIRED FOR INSPECTIONS SIGNED_ 777t- TITLE DATE J AC UIj C R N E TA / AR MENT Ur/ONLY Application Accepted By ate Area4 Employee ID#4", Grout Inspection By Date SPECIAL Well Permit Pump Inspection By hr''i'h(Y�( -�tQe* -h Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Check#/ Amount Permit/ Codes Info B Cash emitted Date Service Request# Invoice# Well ID# R�j d7D Q 3qJD J`, EHD 43-06 WELL/PUMP PERMIT 8/04/08